27Nov11 Where have all the young docs gone?

In my new role as one of the directors of an internal medicine training program, I help select new interns out of medical school for the three year training stint of residency.

At the end of residency, many graduates go on to subspecialty fellowships, another two to four year period of intensive training in fields like cardiology, nephrology, critical care etc.

For those that don’t choose a subspecialty, one choice remains: traditional internal medicine (opening or joining a medical practice) versus becoming a hospitalist.

At this point, it’s no contest. Hospitalists earn  more money. North of $200k.  One standard job format involves fourteen hour shifts, seven days on followed by seven days off. Our graduates are unanimously choosing this path.

I fear that young doctors don’t see value in primary care careers. With health care reform set to kick in in 2014, there will be a tremendous shortage of available doctors for newly-insured patients to see.

I’m reposting a story I wrote about one couple’s painful experience learning about what a hospitalist is. In future posts, I plan to explain the competing tensions between the alternate job pathways in internal medicine and examine the health care workforce as a whole.

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A place many internists no longer see.

A few weeks ago I got a call from Frank Wilson (not his real name).

He told me he and his wife were looking for a new doctor and a new hospital.

Mr. and Mrs. Wilson had been with the same doctor for nearly 20 years. The relationship had been warm, and, he explained, “We trusted him to follow us through thick and thin.”

I could sense the hurt in his voice. Why, I wondered, would they give up on a doctor who knew them so well? Among people of my generation, doctors are switched more than toothpaste.

At a time of need, Mrs. Wilson became sick enough to need the hospital. They called their doctor, let’s call him Dr. Gonomore, and he agreed to see her right away.

Mrs. Wilson was short of breath, and would need to be hospitalized, to figure out exactly what was wrong with her and to offer her the most aggressive treatment.

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20Nov11 Gratitude Redux

In the spirit of Thanksgiving, I want to express my appreciation for many blessings:

Family, health, a new community, meaningful work, and sustenance: from the earth, our colleagues, trainees and friends old and new.

I am reposting an essay about a how the simple act of daily thanks transformed a man’s life for the better. It’s an inspiring story.

I hope that you have a meaningful Thanksgiving.

-GlassHospital

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I just read a book called 365 Thank Yous by John Kralik.

I heard an interview with the author on NPR, and it caught my attention.

Kralik had been down on his luck in 2007: divorced twice, overweight, with a struggling law firm that he’d started, he was also failing in a new romantic relationship. He was worried about losing his seven year-old daughter, too, in a custody dispute.

He made a momentous decision: Instead of feeling sorry for himself (easy to do given his predicaments), he decided to be grateful for what he had. To show it, he vowed to write a thank you note every day for the next year.

What do you think happened?

His life changed. For the better. His relationship improved. His clients started paying their bills and his firm’s financial footing solidified. His health improved. He eventually achieved his lifelong dream of becoming a judge. To top it off, he turned his personal quest into a writing project. Within minutes of writing a book proposal, he received responses from agents who hoped to shepherd his project.

Every writer’s dream……

I’ll grant you that it sounds hokey. But there are a couple of things the book demonstrated to me:

Making a commitment to change is never easy. Kralik decided to change his perspective, and his results are indeed stunning. But he’s quite open about the fact that it was a process, and a lengthy one at that. He had times when he felt like giving up. Crises arose in which he didn’t write a note for several weeks. Sometimes he just flat out felt that he had nothing to be grateful for. But he always came back to his task.

And people really responded to him: from government officials, to clients, to his Starbuck’s barista. Everyone likes gratitude. We are human. It helps to know that our work and our humanity are appreciated.

There are other personal resonances: Kralik hails from Cleveland. Even as a lawyer, he shunned corporate law for his own values-driven law firm. He wrote a mission statement, and was rankled with inner turmoil when he strayed too far from it.

I guess to sum it up I’d write Judge Kralik a thank you letter of my own:

Dear Judge Kralik:

Thank you for sharing your story with me.

I am truly inspired by how you were able to turn your life around. As a doctor, I am touched by the mission-driven aspect of your legal work. In addition, I find that your quest to allow gratitude to suffuse every aspect of your life really provided a beautiful level of harmony to your story. I plan to share your story with patients and colleagues; I am always moved by ideas and examples that take something simple (e.g. the thank you note) and make it a habit that can lead to a virtuous cycle.

Congratulations on your professional and personal successes. I hope that they continue.

Genuinely,

John Henning Schumann, M.D.

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13Nov11 Blue Light Special on Primary Care?

NPR and the Wall Street Journal ran stories this week on Wal-Mart’s attempt to re-shape delivery and provision of primary medical care in the U.S.The company is soliciting proposals from vendors that offer products and services designed to deliver efficient and inexpensive primary care to the market place.

Your new doctor's office?

Then, in an “Oops” moment, the company’s VP for health and wellness issued a statement the next day clarifying his intent: “We are not building a national, integrated, low-cost primary care health care platform.” A company spokeswoman said that the request for proposals was “overwritten and incorrect.”

Huh?

Let’s start with basics: Wal-Mart is the world’s largest retailer. It employs around two million people, far more than any other private sector company in the world. It has combined annual sales of over $400 billion.

Wal-Mart’s success is in large part due to its massive supply chain and innovative inventory logistics. It knows what its customers want, it negotiates strongly on price, and then stocks the items in huge quantities, passing on the savings to customers.

This strategy has fueled unprecedented growth and changed many communities in which the corporation operates.

This is not without controversy: Wal-Mart pays its employees lower than average hourly wages, and does not offer health insurance to a significant portion of its workforce. The company is said to be responsible for 10% of the total exports of China; one website reports that 80% of Wal-Mart’s suppliers are in China.

What’s any of that got to do with health care? I find it an interesting question, one that begets further ones:

  1. Could Wal-Mart use its strategic and logistical excellence to build a robust and cost-effective primary care network?
  2. Would doing any of this improve the company’s corporate image? Imagine Wal-Mart working in service to our national goal of “bending the cost curve” on health care spending, and while doing so providing basic health care services not only to its currently neglected employees, but to the population at large…
  3. Is ‘straightforward’ primary care amenable to widget-ization? Certainly most doctors would argue “NO!”

I will be eager to follow the travails of Wal-Mart as they pursue this enterprise. It may be courageous, outlandish, innovative, and special, or it may become Wal-Mart’s Waterloo.

I just hope that whatever happens with health care, they do a better job than they did with this Chanukah display that’s circulating the Internet.

Giving people what they want?

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6Nov11 Inside Baseball: Health Care Edition

Reader Lisa Livingston submitted this guest post helping demystify one of the very important but poorly understood roles in medical care: radiology technician.

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Most of us have had an x-ray at some point in our lives, and it was probably performed by a radiology technician. But what else does the job entail, and why would someone be interested in it?

What Do They Do?

Radiology technicians perform imaging of the human body for medical treatment. The most common type of imaging is x-ray films, but they may also work with more sophisticated forms of imaging such as fluoroscopy or sonography, which are used to visualize various organs. They may also assist with MRIs or mammograms. They also ensure patient safety before performing imaging, check positioning and operations of equipment, and keep track of patient records.

X-ray of a normal hand.

Where Do They Work?

Radiology technicians may work in hospitals, clinics, medical laboratories, or private practices. They usually work in a room with the diagnostic machines, but they may also perform imaging at a patient’s bedside or even travel to a patient’s home in a van equipped with the necessary diagnostic machines.

What Type of Education is Needed?

Formal training to become a radiology technician can vary. Programs may lead toward a certificate, an associate’s degree, or a bachelor’s degree, though an associate’s degree is the most common. Most programs involve both classroom and clinical instruction in areas such as anatomy, physiology, medical ethics, radiation physics, and pathology. Anyone interested in science, math, technology, and the medical field may be interested in this work.

What Rewards Does the Job Offer?

There are many opportunities for advancement in this job. A radiology technician may specialize in a certain type of imaging. With further education, they could become a radiologist, a supervisor, administrator, or even teach at the university level.

Radiology technicians also have a good amount of job security, because demand for qualified professionals is high. There are jobs available in any area of the country, and the demand isn’t expected to go away for some time.

They also have a significant amount of contact with a variety of people. Radiology technicians contribute to a patient’s treatment in a meaningful way and they will see many different patients on a daily basis. They also make up an important part of a team of other medical professionals such as physicians and radiologists.

What is the Job Outlook?

According to the U.S. Bureau of Labor Statistics, employment is expected to increase by 17 percent by 2018. There will be more demand for diagnostic imaging with the aging Baby Boomer population. As medical technology continues to find new and better ways to treat diseases, diagnostic imaging will constantly be in high demand. There will also be more jobs available as imaging technology becomes less expensive and more clinics invest in them. A radiology technician’s average salary is around $50,000.

Lisa Livingston is a radiologist. She writes about health care and has a website devoted to radiology technician educational information.

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30Oct11 Medical Skepticism, vol. 5

MRI: Irv Fufflik's knee (used with his permission).

Tip of the cap to the St. Louis Cardinals for their inspired comeback and World Series victory.

I offer an even bigger hat tip to famous Alabama orthopedic surgeon Dr. James Andrews for his robust medical skepticism.

Those of you that are sports fans have no doubt heard of Dr. Andrews. He is to pitchers’ elbows, shoulders and knees what Andy Warhol was to Campbell’s Soup.

The Times of New York trendspotted the following big medical news: doctors order too many MRIs.

Shocker, right?

You may have read something like this before; here the difference is that it’s the folks most likely to benefit from the superfluous imaging tests that are decrying their overuse.

Orthopedic surgeons generally only earn income when they perform operations. So it comes as big news when the best and the brightest of the bunch tell us we don’t need the tests that lead them to do operations.

In fact, the technology in the MRI is so good that it defies our understanding of what to actually do with the information it provides.

Here are some key points from the Times article that will save you the trouble of clicking over there:

  1. The details in an MRI are such that a radiologist almost never interprets a study as “normal.”
  2. The irregularities that make an MRI ‘abnormal’ seldom correlate to physical symptoms (more on this below).
  3. As an example: when a healthy runner goes for a jog, she’ll have evidence of ‘abnormal’ fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury.

Dr. Andrews, in a gutsy move, obtained MRIs on the shoulders of 31 professional baseball pitchers. To quote the article:

The pitchers were not injured and had no pain. But the MRIs found abnormal shoulder cartilage in 90 percent of them and abnormal rotator cuff tendons in 87 percent. “If you want an excuse to operate on a pitcher’s throwing shoulder, just get an M.R.I.,” Dr. Andrews says.

In training, I was taught about a study in which 100 consecutive healthy volunteers received MRIs of their low back. Even though none of the subjects had symptomatic back pain, 33 of them had abnormalities on their MRIs, things like disc ‘herniations’ and ‘protrusions.’

What do we do with that information? Should we offer the volunteers surgery that they don’t need?

Dr. Andrews and his orthopedic colleagues are asking themselves the same questions about their patient-athletes.

A take home point: don’t demand an MRI from your doctor if you have a musculoskeletal athletic injury. Time itself heals many wounds.

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